Cardiac Pacemakers Radiology

Cardiac pacemakers: What the radiologist needs to know
Poster No.: C-0741

Congress: ECR 2010
Type: Educational Exhibit
Topic: Cardiac
Authors: 1 2 1 1
F. Gutierrez , S. A. Rossini , S. Bhalla , K. Cummings , C.
2 1 2
Capiel ; St. Louis, MO/US, Mar del Plata/AR
Keywords: Cardiac Pacemakers:, cardiac chambers and cardiac venous
anatomy, post-procedural complications
DOI: 10.1594/ecr2010/C-0741
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Page 1 of 26
Learning objectives
• Knowledge of cardiac chambers and cardiac venous anatomy.
• Be familiar with the most common radiologic aspects of these devices.
• Review the most common and alternative location of the pacemaker leads.
• Localize findings on chest radiography and MDCT.
• Understand alternative lead placement in patients with congenital heart disease.
• Indentify post-procedural complications.
Background
• Cardiac pacemaker and pacemaker cardioverter defibrillator technology (ICD) has

evolved dramatically in the past few years.
• Nevertheless, malfunctions and complications are still found, and frequently,

radiologists are first to identify these situations.
• The radiology information system was queried for patients who had undergone previous
pacemaker or ICD placement, utilizing a variety of approaches. Unusual lead placement
as well as multiple complications were identified. Chest radiographies were reviewed.
Correlation with MDCT images was performed whenever feasible.
Imaging findings OR Procedure details
Page 2 of 26
• We review the cardiac chambers and cardiac venous anatomy and describe the most
common radiologic aspects of the pacemaker and pacemaker cardioverter defibrillator
(ICD).
• We discuss approaches to pacemaker and ICD lead placement in the cardiac chambers,
as well as in the cardiac and thoracic veins.
• Examples of lead placement in patients with normal cardiac anatomy, as well as those
with congenital heart disease, are presented.
• Post-procedural complications, including lead malposition, breakage and migration, are

discussed.
CARDIAC CHAMBERS AND THORACIC VEINS ANATOMY [1]
Fig.: Cardiac chambers and thoracic veins anatomy

References: S. A. Rossini; Ct and MRI, Instituto Radiologico Mar del Plata, Mar del
Plata, ARGENTINA
CARDIAC VENOUS ANATOMY [1]
Page 3 of 26
Fig.: Cardiac venous anatomy
Plata, ARGENTINA
COMPONENTS OF PACEMAKERS
Fig.: Cardiac pacemakers are usually indicated for heart block and sinus node
disorders. These systems are composed of a pulse generator, sensing and pacing
Page 4 of 26
leads which can be placed in different cardiac chambers depending on pacing needs.
These devices were placed intravenously with the generator buried in the chest wall
[2].
Plata, ARGENTINA
Fig.: Cardioverter defibrillator (ICD) are usually implanted in people at high risk of
sudden cardiac death that can provide lifesaving cardioversion in the case of a life-
threatening arrhythmia. Modern ICDs typically have pacemaker capabilities (PCD)
[3,4]. Are composed of a pulse generator, sensing leads and shock-delivery lead(s).
The shock-delivery leads have a platinum-iridium coil electrode (arrowheads) for
cardioversion or defibrillation [5].
Plata, ARGENTINA
Page 5 of 26
Fig.: Occasionally, epicardial lead placement is utilized as an alternative pacing
option. These devices were surgically placed over the pericardium with the generator
buried in the chest or abdominal wall and the lead placement in different anatomic
locations [5].
Plata, ARGENTINA
DIFFERENT LOCATION OF THE PACEMARKER LEADS
Page 6 of 26
Fig.: Atrioventricular Pacemaker with pulse generator in left anterior chest wall, two
leads and electrodes in:Right Atrium Appendage (RAA) Right Ventricle (RV)
Plata, ARGENTINA
Fig.: Biventricular pacemaker with electrodes in: Right Ventricle Coronary Sinus.
A biventricular pacemaker is a type of pacemaker that can pace both right and left
ventricles to resynchronize the heart rhythm, a common problem in heart failure
patients. These pacemakers usually have three leads, one in the right atrium, one in
the right ventricle, and a final one is inserted through the coronary sinus into a cardiac
vein to pace the left ventricle [6].
Plata, ARGENTINA
Page 7 of 26
Fig.: Biventricular pacemaker cardioverter defibrillator (PCD) with electrodes in: Right
Atrium (RA) Right Ventricle (RV) Posterior Vein (Pv).
Plata, ARGENTINA
Fig.: Biventricular PCD with electrodes in: Right Atrium (RA) Right Ventricle (RV)
Anterior Interventricular vein (AIVv).
Plata, ARGENTINA
Page 8 of 26
Posterior vein (Pv) Marginal vein (Mv).
Plata, ARGENTINA
Posterior Interventricular vein (PIVv)
Plata, ARGENTINA
Page 9 of 26
Fig.: Implantable Cardioverter-Defibrillator (ICD) with electrodes in Right Ventricle
(RV) Azygous vein (Av). This location is sometimes selected to provide a suitable
shocking vector between the right ventricular electrode, and a high-voltage lead placed
in the azygous vein [7] .
Plata, ARGENTINA
SOME ANATOMIC VARIANTS
• Left superior vena cava (Case 1).
• Situs Inversus (Case 2).
• Transposition of the Great Arteries (Case 3).
Page 10 of 26
Fig.: Case 1: Left superior vena cava. Dual lead PCD coursing through left superior
vena cava (LSVC) and coronary sinus before ending in the right atrium and right
ventricle.
Plata, ARGENTINA
Fig.: Case 2: Situs inversus. Single lead PCD in a patient with situs inversus totalis
and right superior vena cava. The electrode is in the right ventricle.
Page 11 of 26
Plata, ARGENTINA
Fig.: Case 3: Transposition of the great arteries s/p Mustard operation. Lead travels
through atrial baffle before terminating in posterior (pulmonary) atrium and ventricle
(anatomic LV).
Plata, ARGENTINA
PACEMAKER COMPLICATIONS
• Myocardial perforation (Case 4 to 7).
• Traumatic arterio-venous fistula (Case 8).
• Migration (Case 9).
• Lead dislodgement (Case 10 and 11).
• Lead fracture (Case 12).
Page 12 of 26
Fig.: Case 4: Perforated RV lead. 81 year old woman with syncope after pacer
implantation. Note unusually lateral and posterior location of right ventricular lead and
electrode (arrows).
Plata, ARGENTINA
Page 13 of 26
Fig.: Emergency contrast CT demonstrates lead perforating near RV apex (arrows)
with electrode tip adjacent of left ventricular free wall (arrowheads). Note lack of
hemopericardium.
Plata, ARGENTINA
Page 14 of 26
Fig.: Case 5: RA lead migration and perforation. Patient developed pleuritic chest pain
several days after pacer implantation. On B, note right atrial lead (arrows) migration
and new pleural effusion.
Plata, ARGENTINA
Fig.: CT demonstrates electrode tip (arrow) piercing right atrial wall, hemopericardium
(arrowheads) and pleura effusion.
Plata, ARGENTINA
Page 15 of 26
Fig.: Case 6: Perforated RV lead extending to chest wall. 72 year old man who
developed anterior muscle "twiching" several days after pacer implantation. Distal right
ventricular lead seen projecting outside confines of the heart (arrows).
Plata, ARGENTINA
Page 16 of 26
Fig.: Non-contrast CT demonstrates the lead perforating near the right ventricular
apex (arrow). Arrowheads illustrate extracardiac trajectory before terminating in
anterior chest wall musculature. No hemopericardium is seen.
Plata, ARGENTINA
Page 17 of 26
Fig.: Case 7: RV lead migration to anterior abdomen. Migration of right ventricular lead
over a several day period (arrows).
Plata, ARGENTINA
Page 18 of 26
Fig.: RV lead has pefrorated and its tip (arrows) located below the diaphragm in right
hypochondrium.
Plata, ARGENTINA
Page 19 of 26
Fig.: Case 8: Fistula A-V. 77 year old woman after pacemaker placement. Note
horizontal course of the single ventricular lead (arrows) with tip near hart apex (A).
Non-contrast CT shows how lead passes from left brachiocephalic vein (C) into
adjacent innominate artery (D).
Plata, ARGENTINA
Page 20 of 26
Fig.: Angiography demonstrates passage of the lead through a traumatic arterio-
venous fistula into the arterial system. Electrode tip was in the left ventricle.
Plata, ARGENTINA
Page 21 of 26
Fig.: Case 9: RA lead migration: Radiograph A show correct location of RAA lead.
Radiograph B demonstrates RAA lead migration to the right brachiocephalic vein
(arrow).
Plata, ARGENTINA
Fig.: Case 10: Twiddler's Syndrome. Radiograph A show s correct location of RV

lead. Radiograph B taken 12 months later illustrates change in the position of the
pulse generator and retraction of the RV lead (arrows). Note on B how the continued
twisting of the generator inside the pocket has twisted the lead and fractured part of its
attachment (arrowheads). This complication results from the patient's habit of rotating
or "twiddling" the pulse generator inside its subcutaneous pocket (8).
Plata, ARGENTINA
Page 22 of 26
Fig.: Case 11: Reverse Twiddler 's syndrome. Starting with good lead position on
radiograph A, continued twisting of the generator has caused further introduction
and looping into the ventricular cavity of the lead (arrow) while the electrode remains
anchored in the RV myocardium (radiograph B).
Plata, ARGENTINA
Page 23 of 26
Fig.: Lateral radiograph shows the interventricular lead looping to better advantage
(arrows).
Plata, ARGENTINA
Page 24 of 26
Fig.: Case 12: Lead fracture. Proximal lead fracture (arrow) in typical location subject
to motion and shearing forces. The most common breakage site is at the costal margin
and between the rib and the clavicle (9).
Plata, ARGENTINA
Conclusion
Radiologists must be familiar with current approaches to pacemaker lead placement,

as well as common post-procedural complications. It is important to understand the
cardiothoracic venous anatomy in both normal patients and those with anatomic variants
and congenital heart disease.
Personal Information
References
1. Julie E. Takasugi MD, J. David Godwin II MD. Gust H. Bardy MD. The Implantable
Pacemaker cardioverter Defibrillator: Radiographic Aspects. Radiographics 1994; 14:
1275-1290.
2. Robert M. Steiner MD, Charles J Tegtmeyer MD Dryden Morse MD, et al. The radiology
of cardiac pacemakers. Radiographics 1986; 6: 373-399.
Page 25 of 26
3. Winkle RA, Mead RH, Buben MA, et al. Long-term outcome with the auto-matic
cardioverter defibrillator. J Am Coll Cardiol 1989; 13: 1353-1361.
4. Gerard Eagar, Fernando R Gutierrez, M Carolyn Gamache. Radiologic Appearance

of Implantable Cardiac Defibrillators. AJR 1994; 162: 25-29. 5. Karoly Kaszala MD, Jose
Huizar MD, Kenneth Ellenbogen MD. Contemporary Pacemakers: Whath the primary
care physician needs to know. Mayo Clin Proc 2008; 83 (10): 1170-1186.
6. Parsonnet V. An intracardiac bipolar electrode for interior treatmnet of complete heart

block. Ann Cardiol 1962; 10: 261.
7. Nicholas P. Gall MD, Francis D. Murgatroyd MD. Electrical cardioversion for AF The
state of the art. J Cardiovasc Electrophysiol 2004. 15: 780-730.
8. Mehta D, Lipsius M, Suri RS, et al. Twiddler's syndrome with the implantable
cardioverter-defibrillator. AM Heart J 1992: 123: 1079-1082.
9. Rosenbaum HD. Roentgen demostration of broken cardiac pacemaker wire. Radiology

1965: 84: 933.
10. Brad A. Racette, Keith M. Rich, Jennifer Randle, Jonathan W. Mink. Ipsilateral
Thalamic Stimulation after Thalamotomy for Essential Tremor.A Case Report. Stereotact
Funct Neurosurg 2000;75:155-159.
11. George Mark S. et al (2000). Vagus Nerve Stimulation: A New Tool for Brain Research
and Therapy. Biological Psychiatry, 47, 287-295.
Page 26 of 26

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Cardiac pacemakers: What the radiologist needs to know

Poster No.: C-0741

• Knowledge of cardiac chambers and cardiac venous anatomy.

• Be familiar with the most common radiologic aspects of these devices.

• Localize findings on chest radiography and MDCT.

• Understand alternative lead placement in patients with congenital heart disease.

• Indentify post-procedural complications.

• Cardiac pacemaker and pacemaker cardioverter defibrillator technology (ICD) has

• Nevertheless, malfunctions and complications are still found, and frequently,

Imaging findings OR Procedure details

• Post-procedural complications, including lead malposition, breakage and migration, are

CARDIAC CHAMBERS AND THORACIC VEINS ANATOMY [1]

Fig.: Cardiac chambers and thoracic veins anatomy

CARDIAC VENOUS ANATOMY [1]

DIFFERENT LOCATION OF THE PACEMARKER LEADS

SOME ANATOMIC VARIANTS

• Left superior vena cava (Case 1).

• Situs Inversus (Case 2).

• Transposition of the Great Arteries (Case 3).

• Myocardial perforation (Case 4 to 7).

• Traumatic arterio-venous fistula (Case 8).

• Migration (Case 9).

• Lead dislodgement (Case 10 and 11).

• Lead fracture (Case 12).

Fig.: Case 10: Twiddler's Syndrome. Radiograph A show s correct location of RV

Radiologists must be familiar with current approaches to pacemaker lead placement,

4. Gerard Eagar, Fernando R Gutierrez, M Carolyn Gamache. Radiologic Appearance

6. Parsonnet V. An intracardiac bipolar electrode for interior treatmnet of complete heart

9. Rosenbaum HD. Roentgen demostration of broken cardiac pacemaker wire. Radiology

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